What Causes Chronic Chest Pain?

Patient Presentation
An 8-year-old male came to clinic complaining of left sided intermittent chest pain for 2 months. The pain is in the anterior or slightly lateral chest. It lasts for ~2-3 seconds coming on abruptly and then leaving abruptly. It occurrs at any time including rest or mild exercise (like walking) but not during sleep. The episodes happen 3-4 times/week and ~ 1-3 times/day. There was no radiation, palpitations, racing heart, shortness of breath, dizziness or fainting. The episodes possibly occurr with inhalation. He is alert during the episodes and they frightened him at first but now they are just bothersome.
His past medical history reveals that he has attention deficit disorder for which he was begun on a long acting stimulant medication about 2 months ago. He had no recent illnesses.
His family history reveals no hypercholesterolemia and a grandfather with myocardial infarction after age 50.
On physical examination his weight and height are normal. Pulse = 72, blood pressure = 92/65. His cardiac examination shows a normal S1, S2, no murmurs. He has no jugular venous distention and normal cardiac waves in his neck. No bruits are heard in the neck or abdomen. Lungs are clear. There is no organomegaly. Peripheral pulses in the upper extremities are equal to the lower extremities in intensity and timing. His nailbeds showed no clubbing or cyanosis.
Laboratory evaluation of an electrocardiogram was normal.
A clinical diagnosis of precordial catch syndrome was made. The patient was instructed to maintain a symptom diary and was to report any changes especially if there was a change in the character, intensity, location, or associated symptoms.

The cause of precordial catch syndrome (Texidor’s twinge or a stitch in the side) is unknown but it is a benign illness with no significant side effects. It usually occurs in teens and pre-teens. It has a sudden onset of intense, sharp pain in the chest or back usually with inhalation. It can occur for a few seconds to minutes and generally resolves spontaneously. It is not associated with exertion.
Several episodes may occur per day and the frequency of the episodes decreases with time.

Stimulant medication for Attention Deficit Disorder has some potential side effects. The most common ones are anorexia, weight loss and sleep disturbances. Additionally, stimulant medication may also potentially cause the unmasking of tic disorders or lower seizure thresholds. Tachyarrhythmias can be seen with stimulant medication but by themselves generally do not cause chest pain. Tachyarrhythmias also usually respond to decreasing the medication dosing or interval. Other possible side effects include rash, nausea, emesis, abdominal pain, changes in blood pressure, restlessness, headaches, fever, tremor, mood changes, abnomral liver function tests and scalp hair loss.

Learning Point
The differential diagnosis of chest pain in a child is very different then that of an adult. Chest pain is more often a presenting symptom of a pulmonary or musculoskeletal problem in children rather than a cardiac problem.
The differential diagnosis of chest pain may include:

  • Cardiac
    • Ischemic ventricular dysfunction
      • Hypertrophic obstructive cardiomyopathy
      • Severe pulmonic stenosis
      • Severe aortic stenosis
      • Mitral valve prolapse
      • Myocardial infarction
      • Aortic aneurysm or dissection
      • Anomylous coronary arteries
      • Kawasaki disease
    • Inflammatory conditions
      • Myocarditis
      • Pericarditis
      • Kawasaki disease
      • Postpericardiotomy syndrome
    • Arrhythmias
      • Supraventricular tachycardia
      • Premature ventricular tachycardia
  • Gastrointestinal
    • Esophageal foreign body
    • Gastroesophageal reflux
  • Hematologic/Oncologic
    • Tumors
    • Sickle cell disease with acute chest syndro,e
  • Infections
    • Herpes zoster
    • Coxsackie virus with pleurodynia
  • Musculoskeletal
    • Musculoskeletal trauma
    • Costochondritis
    • Strain – overuse including coughing
  • Pulmonary
    • Pneumonia
    • Pleuritis
    • Spontaneous pneumothorax/pneumomediastinum
    • Asthma
    • Pleural effusion
    • Pulmonary embolism
  • Psychogenic
    • Anxiety
    • Hyperventilation
    • Drug abuse
    • Conversion symptoms
    • Depression
    • Somatization
  • Other
    • Breast tenderness

This child had an electrocardiogram performed because of the timing of initiation of stimulant medication and the chest pain. The electrocardiogram was normal and although the patient was somewhat young, he had a history that was consistent with precordial catch syndrome. The family was reassurred that it was unlikely there was significant underlying pathology as a cause of this child’s chest pain. They were asked to monitor him closely and return if any changes did occur in the future.

Questions for Further Discussion
1. How common is a myocardial infarction in a healthy child?
2. What health problems would increase the likelyhood of a myocardial infaction for a child?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Chest Pains.

Park MK. Pediatric Cardiology for Practitioners. 3rd edition. Mosby, St. Louis, MO. 1996;443-451.

Gunn VL, Nechyba C. The Harriet Land Handbook. 16th edition. Mosby, St. Louis, MO. 2002:756.

Woodhead JC. Pediatric Clerkship Guide. Mosby., St. Louis MO, 2003. pp. 183-185.

Cincinnati Children’s Hospital. Chest Pain. Available from the Internet at: http://www.cincinnatichildrens.org/health/heart-encyclopedia/signs/chest.htm (rev.2004, cited 11/1/04)

Perry P, Kuperman S. Attention-Deficit Hyperactivity Disorder Pharmacotherapy. Available from the Internet at: http://www.vh.org/adult/provider/psychiatry/CPS/39.html (rev. 5/04, cited 11/1/04)

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

November 22, 2004